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Despite the great progress in screening techniques and medical treatments, colorectal cancer remains one of the most widespread cancers in both sexes, with a high death rate. In this work, the volatile compounds released from human colon cancer tissues were detected by a set of four different chemoresistive sensors, made with a nanostructured powder of metal-oxide materials, inserted into an innovative patented device. The sensor responses to the exhalation of a primary cancer sample and of a healthy sample (both of the same weight, collected during colorectal surgery from the intestine of the same patient) were statistically analyzed. The sensors gave reversible, reproducible, and fast responses for at least one year of continuous use, making them quite superior in respect to the existing diagnostic methods. Preliminary results obtained using principal component analysis of the sensor responses to samples removed from 13 patients indicate that the nanostructured sensors employed in this study were able to distinguish between healthy and tumor tissue samples with coherent responses (the discrimination power of the most sensitive sensor was about 17%), highlighting a strong potential for clinical practice.

Introduction Damage control surgery (DCS) is the classic approach to manage severe trauma and has recently also been considered an appropriate approach to the treatment of critically ill patients with severe intra-abdominal sepsis. The purpose of the present review is to evaluate the outcomes following DCS for Hinchey II–IV complicated acute diverticulitis (CAD). Methods A comprehensive systematic search was undertaken to identify all randomized clinical trials (RCTs) and observational studies, irrespectively of their size, publication status, and language. Adults who have undergone DCS for CAD Hinchey II, III, or IV were included in this review. DCS is compared with the immediate and definitive surgical treatment in the form of HP, colonic resection, and primary anastomosis (RPA) with or without covering stoma or laparoscopic lavage. We searched the following electronic databases: PubMed MEDLINE, Scopus, and ISI Web of Knowledge. The protocol of this systematic review and meta-analysis was published on Prospero (CRD42020144953). Results Nine studies with 318 patients, undergoing DCS, were included. The presence of septic shock at the presentation in the emergency department was heterogeneous, and the weighted mean rate of septic shock across the studies was shown to be 35.1% [95% CI 8.4 to 78.6%]. The majority of the patients had Hinchey III (68.3%) disease. The remainder had either Hinchey IV (28.9%) or Hinchey II (2.8%). Phase I is similarly described in most of the studies as lavage, limited resection with closed blind colonic ends. In a few studies, resection and anastomosis (9.1%) or suture of the perforation site (0.9%) were performed in phase I of DCS. In those patients who underwent DCS, the most common method of temporary abdominal closure (TAC) was the negative pressure wound therapy (NPWT) (97.8%). The RPA was performed in 62.1% [95% CI 40.8 to 83.3%] and the 22.7% [95% CI 15.1 to 30.3%]: 12.8% during phase I and 87.2% during phase III. A covering ileostomy was performed in 6.9% [95% CI 1.5 to 12.2%]. In patients with RPA, the overall leak was 7.3% [95% CI 4.3 to 10.4%] and the major anastomotic leaks were 4.7% [95% CI 2.0 to 7.4%]; the rate of postoperative mortality was estimated to be 9.2% [95% CI 6.0 to 12.4%]. Conclusions The present meta-analysis revealed an approximately 62.1% weighted rate of achieving GI continuity with the DCS approach to generalized peritonitis in Hinchey III and IV with major leaks of 4.7% and overall mortality of 9.2%. Despite the promising results, we are aware of the limitations related to the significant heterogeneity of inclusion criteria. Importantly, the low rate of reported septic shock may point toward selection bias. Further studies are needed to evaluate the clinical advantages and cost-effectiveness of the DCS approach.

Background: Indocyanine green fluorescence vision is an upcoming technology in surgery. It can be used in three ways: angiographic and biliary tree visualization and lymphatic spreading studies. The present paper shows the most outstanding results from an health technology assessment study design, conducted on fluorescence-guided compared with standard vision surgery. Methods: A health technology assessment approach was implemented to investigate the economic, social, ethical, and organizational implications related to the adoption of the innovative fluorescence-guided view, with a focus on minimally invasive approach. With the support of a multidisciplinary team, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaires and self-reported interviews, considering the dimensions resulting from the EUnetHTA Core Model. Results: From a systematic search of literature, we retrieved the following studies: 6 on hepatic, 1 on pancreatic, 4 on biliary, 2 on bariatric, 4 on endocrine, 2 on thoracic, 11 on colorectal, 7 on urology, 11 on gynecology, 2 on gastric surgery. Fluorescence guide has shown advantages on the length of hospitalization particularly in colorectal surgery, with a reduction of the rate of leakages and re-do anastomoses, in spite of a slight increase in operating time, and is confirmed to be a safe, efficacious, and sustainable vision technology. Clinical applications are still presenting a low evidence in the literature. Conclusion: The present paper, under the patronage of Italian Society of Endoscopic Surgery, based on an HTA approach, sustains the use of fluorescence-guided vision in minimally invasive surgery, in the fields of general, gynecologic, urologic, and thoracic surgery, as an efficient and economically sustainable technology.

Introduction: Transverse colon cancer (TCC) is poorly studied, and TCC cases are often excluded from large prospective randomized trials because of their complexity and their potentially high complication rate. The best surgical approach for TCC has yet to be established. The aim of this large retrospective multicenter Italian series is to investigate the advantages and disadvantages of both hemicolectomy and transverse colectomy in order to identify the best surgical approach. Materials and methods: This was a retrospective cohort study of patients with mid-transverse colon cancer treated with a segmental colon resection or an extended hemicolectomy (right or left) between 2006 and 2016 in 28 high-volume (more than 70 procedures/year) Italian referral centers for colorectal surgery. Results: The study included 1529 patients, 388 of whom underwent a segmental resection while 1141 underwent an extended resection. A higher number of complications has been reported in the segmental group than in the extended group (30.1% versus 23.6%; p 0.010). In 42 cases the main complication was the anastomotic leak (4.4% versus 2.2%; p 0.020). Recovery outcomes also showed statistical differences: time to first flatus (p 0.014), time to first mobilization (p 0.040), and overall hospital stay (p < 0.001) were significantly shorter in the extended group. Even if overall survival were similar between the groups (95.1% versus 97%; p 0.384), 3-year disease-free survival worsened after segmental resection (78.1% versus 86.2%; p 0.001). Conclusions: According to our results, an extended right colon resection for TCC seems to be surgically safer and more oncologically valid.

Background: In the past three decades, different High Energy Devices (HED) have been introduced in surgical practice to improve the efficiency of surgical procedures. HED allow vessel sealing, coagulation and transection as well as an efficient tissue dissection. This survey was designed to verify the current status on the adoption of HED in Italy. Methods: A survey was conducted across Italian general surgery units. The questionnaire was composed of three sections (general information, elective surgery, emergency surgery) including 44 questions. Only one member per each surgery unit was allowed to complete the questionnaire. For elective procedures, the survey included questions on thyroid surgery, lower and upper GI surgery, proctologic surgery, adrenal gland surgery, pancreatic and hepatobiliary surgery, cholecystectomy, abdominal wall surgery and breast surgery. Appendectomy, cholecystectomy for acute cholecystitis and bowel obstruction due to adhesions were considered for emergency surgery. The list of alternatives for every single question included a percentage category as follows: “ < 25%, 25–50%, 51–75% or > 75%”, both for open and minimally-invasive surgery. Results: A total of 113 surgical units completed the questionnaire. The reported use of HED was high both in open and minimally-invasive upper and lower GI surgery. Similarly, HED were widely used in minimally-invasive pancreatic and adrenal surgery. The use of HED was wider in minimally-invasive hepatic and biliary tree surgery compared to open surgery, whereas the majority of the respondents reported the use of any type of HED in less than 25% of elective cholecystectomies. HED were only rarely employed also in the majority of emergency open and laparoscopic procedures, including cholecystectomy, appendectomy, and adhesiolysis. Similarly, very few respondents declared to use HED in abdominal wall surgery and proctology. The distribution of the most used type of HED varied among the different surgical interventions. US HED were mostly used in thyroid, upper GI, and adrenal surgery. A relevant use of H-US/RF devices was reported in lower GI, pancreatic, hepatobiliary and breast surgery. RF HED were the preferred choice in proctology. Conclusion: HED are extensively used in minimally-invasive elective surgery involving the upper and lower GI tract, liver, pancreas and adrenal gland. Nowadays, reasons for choosing a specific HED in clinical practice rely on several aspects, including surgeon’s preference, economic features, and specific drawbacks of the energy employed.

Introduction: The incidence of anastomotic leak (AL) has not decreased over the past decades and some important grey areas remain in its definition, prevention, and management. The aim of this study was to reach a national consensus on the definition of AL and to identify key points to be applied in clinical practice. Methods: A 3-step modified Delphi method was used to establish consensus. Ten representative members of the major Italian surgical scientific societies with proven colorectal expertise were selected after a call to action. After a comprehensive literature search, each expert drew a list of evidence-based statements which were voted in round one by the scientific board. Panel members were asked to mark “totally disagree”, “partially agree” or “totally agree” for each statement and provide comments. The same voting method was used for round 2. Round 3 consisted of a final face-to-face meeting. Results: Thirty-three statements (clustered into 14 topics) were included in round 1. Following the third voting round, a final list of 16 items was formulated, which encompass the following 9 topics: AL definition, patient- and operative-related risk factors, prevention measures, bowel preparation, surgical technique, intraoperative assessment, early diagnosis, radiological diagnosis and management of specific patterns of AL. The overall response rate was 100% for all items in all the three rounds. Conclusions: This Delphi survey identified items that expert colorectal surgeons agreed were important to be applied in the prevention, diagnosis, and management of AL. This represents the first consensus involving all relevant national scientific societies, defining important and shared concepts in the diagnosis and management of AL.

SummaryBackgroundIn the last two decades, there has been a Copernican revolution in the decision-making for the treatment of Diverticular Disease.PurposeThis article provides a report on the state-of-the-art of surgery for sigmoid diverticulitis.ConclusionAcute diverticulitis is the most common reason for colonic resection after cancer; in the last decade, the indication for surgical resection has become more and more infrequent also in emergency. Currently, emergency surgery is seldom indicated, mostly for severe abdominal infective complications. Nowadays, uncomplicated diverticulitis is the most frequent presentation of diverticular disease and it is usually approached with a conservative medical treatment. Non-Operative Management may be considered also for complicated diverticulitis with abdominal abscess. At present, there is consensus among experts that the hemodynamic response to the initial fluid resuscitation should guide the emergency surgical approach to patients with severe sepsis or septic shock. In hemodynamically stable patients, a laparoscopic approach is the first choice, and surgeons with advanced laparoscopic skills report advantages in terms of lower postoperative complication rates. At the moment, the so-called Hartmann’s procedure is only indicated in severe generalized peritonitis with metabolic derangement or in severely ill patients. Some authors suggested laparoscopic peritoneal lavage as a bridge to surgery or also as a definitive treatment without colonic resection in selected patients. In case of hemodynamic instability not responding to fluid resuscitation, an initial damage control surgery seems to be more attractive than a Hartmann’s procedure, and it is associated with a high rate of primary anastomosis.

Nowadays, the demand for devices capable of efficiently identifying the presence of various biomarkers in human body, connected to a wide variety of pathologies, is progressively increasing. Chemoresistive semiconductor sensors, capable of changing their conductance depending on the chemical reactions between their surface and gaseous analytes, could be a suitable choice for medical devices implementation. In this work, a prototype based on an array of nanostructured sensors was tested, in order to detect the presence of airborne tumor markers in blood samples. These chemicals were conveyed to sensors with an air-flow circuit, equipped with antibacterial filters to maintain the sterility of the system. Resulting signals were acquired, processed and plotted thanks to a custom-made software, realized in Labview®. Statistics on these signals was performed by means of Principal Component Analysis. Both male and female subjects, ranging between 21 to 91 years of age, have accepted to participate in this study, donating their blood samples. Donors were patients affected by colorectal and stomach cancers, at different stages of evolution, and/or having differently localized metastasis, and a healthy control group. The results have shown that the processed sensor responses, well discriminate healthy and tumor affected subjects. Obtained results can be also employed to assess the level of tumor growth and vascularization.

Locally advanced rectal cancer is usually treated with a preoperative approach with radiochemotherapy followed by surgery. Patients obtaining a pathologic complete response have a very favorable long-term prognosis. This study was intended to assess whether major surgery can reduce tumor recurrences and prolong survival of patients with a complete response after radiochemotherapy. Computerized literature search was performed to identify relevant articles. Comparative studies reporting the outcomes of non-operative and operative management in patients after neoadjuvant treatment were reviewed. Data synthesis was performed using Review Manager 5.0 software. Twelve non-randomized comparative studies with a total of 1812 patients were suitable for analysis. There was no significant difference in overall survival at 3 and 5 years (odds ratio [OR] 1.31; 95% CI 0.64–2.69; p = 0.46 and 1.48; 95% CI 1.00–2.20; p = 0.50) and in disease-free survival at 3 and 5 years (odds ratio [OR] 1.20; 95% CI 0.68–2.14; p = 0.53 and 1.22; 95% CI 0.86–1.74; p = 0.26, respectively) between locally advanced rectal cancer patients treated with and without operative approach. Major surgery does not seem to improve prognosis in patients obtaining a complete response after radiochemotherapy. Clinical trials, using clear criteria to identify complete response patients, are needed to recommend non-operative approach.

One of the greatest goals in medicine is early-stage detection of tumors, to allow physicians and surgeons to apply the available therapies, which are usually successful on small volume cancers only. [...]

The demand for reliable devices to detect tumor biomarkers in human body is constantlyincreasing [...]

Colorectal cancer is the third most prevalent cancer in the world, preceded by prostate and lung cancers in men (10%) and breast and lung cancers in women (9.4%). Colorectal cancer is the fourth leading cause of death in men (7.6%) and the third in women (8.6%). A multidisciplinary approach has radically changed the way we deal with this disease among all specialist fields. In this study, we propose comparing the multidisciplinary experience group (started in 2012) of S. Anna Hospital (University of Ferrara) with the previous approach to rectal cancer before the advent of the multidisciplinary program. We find that more study depth of neoplastic disease as well as of each individual patient leads to more accurate staging and to a weighted therapy based on the needs of the individual. All the studies were performed in accordance with the guidelines established by the European and Italian associations.

Early-stage tumor detection is one of the most coveted goals for the world research community. An effective prevention, associated to reliable screening protocols, is crucial to favor a early diagnosis, allowing doctors and surgeons to intervene with high probabilities of success on tumor affected patients. The main purpose of this study is cancer detection, exploiting the volatile organic compounds (VOCs) produced by cancer cells as tumor biomarkers [1][2], by investigating tumor tissue and blood samples. Tumor biomarkers exhalation is attributed to two main cell involving biological mechanisms: altered metabolism and cellular membrane peroxidation [3]. This experimental work was carried on using an innovative, fast-responding and reliable patented device, named SCENT B1 [4], entirely designed and assembled in the Sensor Laboratory of the University of Ferrara. It hosts an array of four specific metal-oxide (MOX) sensors able to detect gases in low concentration (up to 10 ppm) with high stability and repeatability, chosen after many tests on different types of biological samples (feces, blood, cell cultures, etc.) [5,6]; the chosen sensors are based on different mixtures of tin, titanium, tungsten, niobium, tantalum and vanadium oxides (ST25Au, W11, STN, TiTaV). Moreover, SCENT B1 is gifted of a power supply and sensor signal transduction electronic boards, a pneumatic air system (necessary to direct the VOCs contaminated air from the sample chamber to the sensors) and an ad hoc management and data acquisition software (LSS4) [6]. The sensor output signal is a voltage directly proportional to the sensor conductance, depending on the chemical redox reactions taking place on the surface of the sensor sensing material. The sensor response is: R=Vgas/Vair , where Vgas and Vair are the sensor voltage in gas presence and in dry air after the steady state achievement respectively [6].Sensor responses were further elaborated, using different statistical approaches as principal component analysis and receiver operating characteristics methods. Measurements have been performed on colorectal cancer and healthy tissues surgically removed from the same operatory piece (directly and far enough from tumor mass respectively) (Figure 1a), and on blood samples collected from tumor affected subjects and healthy ones as controls (Figure 1b). with the future aim of extending the study to other tumor types. All four sensors gave larger responses (although with different amplitudes) to the tumor tissue with respect to the healthy one. Smaller and reproducible responses were given by the breeding ground (DMEM) only, confirming that it does not alter the measurements. The results are consistent with the stronger and altered metabolism of tumor cells, leading them to emit a larger amount of volatile biomarkers with respect to the healthy ones;. All the four sensors hosted by SCENT B1 proved to be capable of distinguishing between healthy and tumor tissue and blood samples, although with different discrimination power. The encouraging results of this feasibility study are the basis of a new in-depth study, which includes also a follow-up protocol based on post surgery blood monitoring of patients. Our future aims foresee the extension of this study to other tumor types and the obtainment of the SCENT B1 clinical validation as oncologic screening device. Figure 1

In this work two devices are presented, named SCENT A1 (A1) and SCENT B1 (B1), composed of chemoresistive sensors. Such devices are capable of discriminating the different compositions of gas mixtures emitted by stools, for colorectal cancer screening (A1), and by blood, for tumors monitoring (B1), according to defined sampling protocols. Results have been acquired by a LabView® software and statistically treated (e.g. quadratic discriminant analysis, QDA) and show to be encouraging with an error of 5% for SCENT A1. Preliminary results of SCENT B1 proved to be promising. Further studies will be carried out for clinically validating the two devices.

One of the greatest goals in medicine is early-stage tumor detection. An effective prevention is crucial to allow physicians and surgeons to intervene on tumor affected patients with the available therapies and surgical techniques with a high probability of success. The purpose of this research relies on the identification of cancer presence by detecting the volatile organic biomarkers directly produced by cancer cells. Cancer cells produce different biomarkers with respect to healthy cells, mainly due to the altered metabolism and cellular membrane peroxidation. This difference can be recognized by using an innovative device manufactured in the Sensor Laboratory of the University of Ferrara, hosting a specific sensor array chosen for biological sample investigation. The sensor array is composed by four chemoresistive metal-oxide nanostructured sensors, able to detect gases in low concentration (up to 1 ppm) with excellent stability and repeatability. In this study, a fast-responding, reliable and reproducible sensing device, named SCENT B1[1], showed to be capable of discriminating cancerous cells from healthy ones, proving to be an efficient and low-invasive screening system. The device combines a specific electronic and pneumatic system to a specifically selected sensor array. The sample is inserted inside a sample box through a support composed by Petri dishes, while a stabilized ambient airflow conveys the exhalations to sensors. Sensor responses are then statistically analyzed by principal component analysis (PCA). Measurements have been performed on cancer and healthy tissues, extracted during surgery from human colon and rectum, with the future aim of extending the study to the other tumor types. Sensors chosen are the following: a mixture of tin and titanium oxides with addition of gold (ST25Au), tungsten oxide (W11), a mixture of tin, titanium and niobium oxides (STN) and a solid solution of titanium oxide, tantalum and vanadium (TiTaV). Sensors have been selected after a feasibility study performed on immortalized cells of diverse types, where sensors responses have been correlated with cell type and cell initial plating concentration of the samples; the measures have been performed after 24, 48, 72 hours of incubation. The sensor output signal is a voltage directly proportional to the sensor conductance; it depends on the chemical redox reactions taking place on sensor surface [2,3]. In Figure (a) the response R=ÄG/G for each sensor is reported, where ÄG is the difference between the sensor conductance with and without the metabolites expelled by the cells of a tissue. All four sensors gave larger responses (although with different amplitudes) to the tumor tissue with respect to the healthy one. Smaller and reproducible responses were given by the breeding ground (DMEM) only, confirming that it does not alter the measurement. The results are consistent with the stronger metabolism of tumor cells with respect to the healthy ones, because the former emits larger amounts of volatile biomarkers [4,5]. Other tests proved also that different initial plating concentrations (250k, 500k and 1M) of cell give increasing responses, as shown in Figure (b). From this study what emerges is that the device is capable of distinguishing different cell samples basing on their health status and concentrations. The encouraging results of this study are the basis of a deepen study for the clinical validation of the device as a oncologic screening device. References [1] SCENT B1, Italian Patent Number: 102015000057717; [2] Zonta, G. Anania, B. Fabbri, A. Gaiardo, S. Gherardi, A. Giberti, V. Guidi, N. Landini, C. Malagù; “Detection of colorectal cancer biomarkers in the presence of interfering gases”; Sensors and Actuators B 218 (2015), 289–295; [3] Zonta, G. Anania, B. Fabbri, A. Gaiardo, S. Gherardi, A. Giberti, N. Landini, C. Malagù, L. Scagliarini, V. Guidi, Preventive screening of colorectal cancer with a device based on chemoresistive sensors. Sensors and Actuators B, 238, 1098–110, 2016. [4] F. Altomare, M. Di Lena, F. Porcelli, L. Trizio, E. Travaglio, M. Tutino, S. Dragonieri, V. Memeo, G. de Gennaro; “Exhaled volatile organic compounds identify patients with colorectal cancer”; British Journal of Surgery 100 (2013), 144-150; [5] Chan, E.C.Y., Koh, P.K., Mal, M., Cheah, P.Y., Eu, K.W., Backshall, A., Cavill, R., Nicholson, J.K., Keun, H.C., 2009. “Metabolic Profiling of Human Colorectal Cancer Using High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HR-MAS NMR) Spectroscopy and Gas Chromatography Mass Spectrometry (GC/MS)”, Journal of Proteome Research 8(1), 352–361; Figure 1

One of the greatest goals in medicine is early-stage tumor detection. An effective prevention is crucial to allow physicians and surgeons to intervene on patients with the available therapies, usually successful on small volume cancers only. The purpose of this research relies on the identification of cancer presence by detecting the volatile organic biomarkers directly produced by cancer cells. Cancer cell biomarkers are different by the ones exhaled by healthy cells and this difference can be recognized by means of a specific chemoresistive sensor array. In this study, a fast-responding, reliable and reproducible sensing technique proved to discriminate cancerous from healthy cells, making it an efficient low invasive screening system. The device employed, named SCENT B1 [1] combines a specific electronic and pneumatic system to a sensor core made of four nanostructured chemoresistive metal-oxide sensors (nanograins with average size of 40-50 nm) manufactured in the Sensor Laboratory of the University of Ferrara. The sample is inserted inside a specific sample box in a specific support composed by Petri dishes, while an ambient airflow, humidity stabilized, conveys the exhalations to sensors. Sensors responses are then analyzed by principal component analysis (PCA). Measurements have been performed on cancer and healthy tissues extracted during surgery from human colon and rectum, with the future aim of extending the study to the other type of tumors. Neoplastic tissues exhibit altered metabolic processes with respect to the metabolism of healthy cells, therefore the chemicals (metabolites) expelled during cellular respiration depend upon the cell health status. Sensors chosen to compose the array have been selected after a feasibility study performed on immortalized cells of diverse types, correlating also sensors responses with cell concentration inside the Petri dish (after 24, 48, 72 hours of incubation). Sensors chosen are: a mixture of tin and titanium oxides with addition of gold (ST25Au), tungsten oxide (W11), a mixture of tin, titanium and niobium oxides (STN) and a solid solution of titanium oxide, tantalum and vanadium (TiTaV). The voltage output of each sensor is directly proportional to its conductance, that depends on the chemical reactions happening on sensor surface [2,3]. In Figure (a) the response R=DG/G for each sensor is reported, where DG is the difference between the sensor conductance with and without the metabolites expelled by the cells of a tissue. All four sensors gave larger responses (although with different amplitudes) to the tumor tissue with respect to the healthy one. Smaller responses were given by the breeding ground (DMEM) only, confirming that it does not alter the measurement. Results are consistent with the stronger metabolism of tumor cells with respect to the healthy ones, because the former emits larger amounts of volatile biomarkers [4,5]. Other tests proved also that different initial plating concentrations (250k, 500k and 1M) of cell give increasing responses, as shown in Figure (b). From this study what emerges is that the the device is capable of distinguishing different cell samples basing on their health status and concentrations, laying the foundation for a deepen study for the clinical validation of the device as a oncologic screening device. References SCENT B1, Italian Patent Number: 102015000057717; Zonta, G. Anania, B. Fabbri, A. Gaiardo, S. Gherardi, A. Giberti, V. Guidi, N. Landini, C. Malagù; “Detection of colorectal cancer biomarkers in the presence of interfering gases”; Sensors and Actuators B 218 (2015), 289–295; Zonta, G. Anania, B. Fabbri, A. Gaiardo, S. Gherardi, A. Giberti, N. Landini, C. Malagù, L. Scagliarini, V. Guidi, Preventive screening of colorectal cancer with a device based on chemoresistive sensors. Sensors and Actuators B, 238, 1098–110, 2016. F. Altomare, M. Di Lena, F. Porcelli, L. Trizio, E. Travaglio, M. Tutino, S. Dragonieri, V. Memeo, G. de Gennaro; “Exhaled volatile organic compounds identify patients with colorectal cancer”; British Journal of Surgery 100 (2013), 144-150; Chan, E.C.Y., Koh, P.K., Mal, M., Cheah, P.Y., Eu, K.W., Backshall, A., Cavill, R., Nicholson, J.K., Keun, H.C., 2009. “Metabolic Profiling of Human Colorectal Cancer Using High-Resolution Magic Angle Spinning Nuclear Magnetic Resonance (HR-MAS NMR) Spectroscopy and Gas Chromatography Mass Spectrometry (GC/MS)”, Journal of Proteome Research 8(1), 352–361; Figure 1

Preventive screening does not only allow to preemptively intervene on pathologies before they can harm the host, but also to reduce the costs of the intervention itself, boosting the efficiency of the NHS (National Health System) by saving resources for other purposes. To improve technology advancements in this field, user-friendly yet low-cost devices are required, and various applications for gas sensors have been tested and proved reliable in past studies. In this work, cell cultures and blood samples have been studied, using nanostructured chemoresistive sensors, to both verify if this technology can reliably detect tumor markers, and if correlations between responses from tumor line metabolites and the screening outcomes on human specimens could be observed. The results showed how sensors responded differently to the emanations from healthy and mutant (for cells) or tumor affected (for blood) samples, and how those results were consistent between them, since the tumoral specimens had higher responses compared to the ones of their healthy counterparts. Even though the patterns in the responses require a bigger population to be defined properly, it appeared that the different macro-groups between the same kind of samples are distinguishable from some of the sensors chosen in the study, giving promising outcomes for further research.

Among the major challenges of medicine today there are screening and early detection of tumors (since the adenoma stage) in order to prevent their degeneration into malignant cancer and/or metastases. In particular, the colorectal cancer shows a high curability rate, up to 90%, if identified when in its benign stage. The Protocol discussed here is proposed to implement the clinical validation of a device consisting of an array of chemoresistive gas sensors made of semiconductor materials, able of identifying the difference between fecal exhalation of healthy subjects and of subjects suffering from high-risk colorectal polyps or tumors. The tests are compared to the results of fecal occult blood test and colonoscopy as a gold standard.

Diffuse pulmonary meningotheliomatosis (DPM) is a parenchymal lung disease characterized by disseminated bilateral minute pulmonary meningothelial-like nodules (MPMNs). These meningothelial-like nodules are classically encountered as benign solitary or multiple pulmonary nodules containing small epithelioid cell collections nestled within normal pulmonary parenchyma.

Background Three-dimensional view in laparoscopic general, gynaecologic and urologic surgery is an efficient, safe and sustainable innovation. The present paper is an extract taken from a full health technology assessment report on three-dimensional vision technology compared with standard two-dimensional laparoscopic systems. Methods A health technology assessment approach was implemented in order to investigate all the economic, social, ethical and organisational implications related to the adoption of the innovative three-dimensional view. With the support of a multi-disciplinary team, composed of eight experts working in Italian hospitals and Universities, qualitative and quantitative data were collected, by means of literature evidence, validated questionnaire and self-reported interviews, applying a final MCDA quantitative approach, and considering the dimensions resulting from the EUnetHTA Core Model. Results From systematic search of literature, we retrieved the following studies: 9 on general surgery, 35 on gynaecology and urology, both concerning clinical setting. Considering simulated setting we included: 8 studies regarding pitfalls and drawbacks, 44 on teaching, 12 on surgeons’ confidence and comfort and 34 on surgeons’ performances. Three-dimensional laparoscopy was shown to have advantages for both the patients and the surgeons, and is confirmed to be a safe, efficacious and sustainable vision technology. Conclusions The objective of the present paper, under the patronage of Italian Society of Endoscopic Surgery, was achieved in that there has now been produced a scientific report, based on a HTA approach, that may be placed in the hands of surgeons and used to support the decision-making process of the health providers. Electronic supplementary material The online version of this article (10.1007/s00464-017-6006-y) contains supplementary material, which is available to authorized users.

Medical studies have shown that tumor growth is accompanied by protein changes that may lead to the peroxidation of the cell membrane, with consequent emission of volatile organic compounds (VOCs). VOCs can be detected through breath or intestinal gases and are biomarkers for colorectal cancer (CRC). The analysis of VOCs represents a non-invasive and potentially inexpensive pre-screening technique. An array of chemoresistive gas sensors, based on screen-printed Metal OXide (MOX) semiconducting films, has been selected to identify gaseous compounds of oncological interest, i.e. benzene, 1-iodo-nonane and decanal, from the main interferers that can be found in the intestine. MOX sensors are able to detect concentrations down to about 10th ppb, as experimentally proven in previous works, so they can identify very slight differences in concentration among gas mixtures. In this work it has been proven that the array used is able to identify tumor markers singularly and in combination with other gases both in wet and dry conditions. Moreover, the sensors chosen can discriminate target VOCs from interferers even at low concentrations.

A partial anomalous pulmonary venous connection (PAPVC) is a rare congenital defect in which at least one pulmonary vein doesn't drain into the left atrium but into a systemic vein or even into the right atrium, causing a left-to right shunt. PAPVC with a small amount of shunt are usually asymptomatic, and can not be detected during lifetime. Nevertheless, if those patients undergo a major lung resection, the surgical procedure could precipitate right heart failure if this anomalous shunt remains uncorrected. Therefore, it is considered to be very important preoperative diagnosis. In case report, we present a case of a 54-year-old woman with a right upper lobe non-small cell lung cancer and previous history of left lung resection for tuberculosis. During surgery, an anomalous pulmonary vein branch draining into the superior vena cava was incidentally detected. The abnormality was diagnosed as a PAPVC. A right upper open lobectomy was performed. The anomaly was corrected and the surgery was successful without postoperative complications. Surgeons should be aware of this rare anomaly and carefully evaluate preoperative images CT scans of the pulmonary veins.

Introduction Solitary fibrous tumor of the pleura is an uncommon tumor with an indolent course and a good prognosis after surgical resection. However, the tumor occasionally follows an unpredictable clinical course and malignant transformation has been reported to increase the rate of local recurrence. Solitary extrathoracic metastasis from solitary fibrous tumor of the pleura is an uncommon finding. Case Presentation In this case report we present the first case of a synchronous single pulmonary and pancreatic metastasis treated with minimally invasive surgery. Conclusions Pancreatic recurrence should be considered in the postoperative follow-up in patients with solitary fibrous tumor of the pleura.

Colorectal cancer is one of the widely diffused tumors. Despite its high curable rate, if diagnosed in its polyp state, an efficient screening method is highly desirable for preventing and decreasing deaths. Tumor biomarkers, emitted by the peroxidation of the cell membrane, may alter the composition of feces. We developed an array of chemoresistive sensors (both metal oxides and sulfides) capable of distinguishing between real stool samples of healthy subjects and of patients with colorectal cancer at diverse degeneration stages. Preliminary clinical validation of real samples was carried out. Results have shown the selectivity of the sensor array towards tumor affected and healthy subject samples. A quadratic discriminant analysis was performed, with a classification error of about 5%.

Colorectal cancer screening is fundamental to decreased mortality related to the target disease. This pathology is diffused worldwide for both men and women and its curability rate, when identified at stage I, is up to 90%. Fecal occult blood test is currently the methodology adopted in many countries as a screening on population, but it shows a very high percentage of false positives, leading to non-operative colonoscopies performed on people who are often elderly and already debilitated. The use of an economic and easy-to-use method alongside fecal occult blood test would improve effectiveness of the screening. Here, the results so far obtained in the clinical validation protocol, started in May 2016, using a patented device with a core of chemoresistive gas sensors, are shown. The device can identify the difference between the fecal exhalation odor of two categories of subjects: healthy and those affected by high-risk adenomas or tumors. Moreover, further calibration of the instrument for the recognition of low-risk adenomas is on-going. The tests are compared to fecal occult blood test positives and colonoscopy results. In this work the most recent results as well as improvements in screening method are presented, useful for future large-scale production of the device.

Due to the steady increase in the elderly population, the issue of frail patients with acute abdomen management is ever more actual. Many questions remain unsolved, concerning both the indication to surgery and the type of surgical approach, open or laparoscopic. This chapter describes the specific problems of the elderly patient, providing to the emergency surgeon, who has to take a quick and often lonely therapeutic choice, a survey of the literature upon which to base a rational approach to treating frail patients with acute abdomen. Some diseases, such as cholecystitis, appendicitis, and complicated Hinchey stage 3 diverticulitis, can be treated with laparoscopic approach, if the answer to a series of 11 questions is always “yes.”

Laparoscopy has become a common procedure in elective surgery worldwide. Actually, it can be considered the preferred surgical approach in various diseases, due to its sure advantages. The last decade has been characterized by the increasing numbers of surgeons trained to a high standard in minimally invasive surgery and by the validation of laparoscopic procedures in emergency surgery. However, despite the undisputed advantages of laparoscopy (such as the shorter hospital stay, the faster recovery, and the less morbidity), the advances in technology, and a structured training for young surgeon that have stimulated the spread of the laparoscopic procedure in the world, the perception has hovered for many years that laparoscopic surgery should remain the preferred approach only in case of elective fields.

Laparoscopic surgery has become well established in the management of both benign as malignant colorectal disease. However there has not been the same enthusiasm for the use of laparoscopy in emergency colorectal surgery. We have critically review the indications and the results of the laparoscopic approach for the treatment of acute colorectal disease. A systemic review based on comprehensive Literature research was made on Pubmed with the primary objective to identify all clinical relevant randomized controlled trials (RCT). However, other reports, population based outcomes studies, case series and case reports were also included. Cross-link control was than performed with Google Scholar and Cochrane library databases. We have reviewed the last years' evident literature about this last topic and the results reported , although mainly early, controversial and focused on the short term, enabled us to generally conclude that in a proper setting, laparoscopic colorectal emergency surgery is feasible, effective, safe and beneficial for patients to be a part of a common surgical practice, as long as adequate training is obtained and proper preparation observed when more advanced procedures are attempted in critically patients.

The complications to perforated ulcers remain one of the most frequent causes of death and disability worldwide. While the incidence and mortality of bleeding ulcers have decreased, The rates of perforated peptic ulcers have largely been unchanged in the past decades. The mini-invasive technique, as in other fields, has been widerly adopted to treat a PPU, because it allows the advantages of laparoscopic surgery. However, even today, the lack of confirmed real advantages of laparoscopy, compared to traditional treatment, have partially limited the spread. Further evaluation and, especially, wider and more numerous trials of quality (RCT) are needed.

Pancreaticoduodenal artery (PDA) aneurysm associated with a celiac artery (CA) occlusion or stenosis is an uncommon event. We report the case of a 63-years old man who presented with acute abdominal pain radiating to the back. During the hospital stay, the patient had an episode of severe hematemesis. He had a gastroscopy and then a surgical exploration. However only with arteriography we found a PDA, which had ruptured into duodenum. The aneurysm was associated with a stenosis of the celiac trunk and was supplied by a dense network of collateral vessels from the SMA. The patient was successfully treated with embolization and was discharged on the 64th postoperative day. Short term and mid term follow-up was uneventful. This case shows the difficulty in diagnosing these rare events in time, indicating that angiography is indispensable to establish a diagnosis and enable nonsurgical treatment.

A 38-year-old patient had a right radical (Patey) mastectomy for an infiltrating ductal carcinoma followed by chemotherapy and, one year later, a TRAM flap breast reconstruction. She was given clear and exhaustive information about the possible consequences of pregnancy, but despite this she became pregnant four months after the reconstruction. The pregnancy was taken to term despite the appearance at four months of a slow-growing abdominal hernia. In the light of our experience and that of others, we recommend an interval of at least 12 months between breast reconstruction with a TRAM flap and pregnancy.

Large core biopsy is a recently introduced method for pre-operative evaluation of breast lumps. The aim of this study was to evaluate the usefulness of this technique in providing pre-operative diagnostic and prognostic information that can lead to a correct line of treatment. We compared 41 cases of breast carcinomas diagnosed both by core biopsies and surgically removed samples. A high (93%) diagnostic agreement was obtained. Moreover, we found a significant correlation for mitotic count (r = 0.76), oestrogen receptor (r = 0.78), progesterone receptor (r = 0.80), p53 (r = 0.86) and c-erbB-2 (r = 0.90) analysis between core biopsy and definitive surgical pathology. An agreement for histological grading evaluation between the two techniques was obtained in 32 out of 40 cases (k = 0.65) whereas in the other cases, a lower grade was assigned by evaluating core biopsies. These findings suggest that percutaneous core breast biopsy is a valid tool for pre-operative management of breast lesions, but this should be confirmed in larger, prospective studies.

To study the short-term outcome of patients treated with laparoscopic right colectomy and how intracorporeal anastomosis has improved the outcome.We retrospectively examined all patients affected by colorectal cancer who underwent a laparoscopic right colectomy between January 2006 and December 2010 in our department. Our evaluation criteria were: diagnosis of colorectal carcinoma at presurgical biopsy, elective surgery, and the same surgeon. We excluded: emergency surgery, conversions from laparotomic colectomy, and other surgeons. The endpoints we examined were: surgical time, number of lymph nodes removed, length of stay (removal of nasogastric tube, bowel movements, gas evacuation, solid and liquid feeding, hospitalization), and major complications. Seventy-two patients were divided into two groups: intracorporeal anastomosis (39 patients) and extracorporeal anastomosis (33 patients).Significant differences were observed between intracorporeal vs extracorporeal anastomosis, respectively, for surgical times (186.8 min vs 184.1 min, P0.001), time to resumption of gas evacuation (3 d vs 3.5 d, P0.001), days until resumption of bowel movements (3.8 d vs 4.9 d, P0.001), days until resumption of liquid diet (3.5 d vs 4.5 d, P0.001), days until resuming a solid diet (4.6 d vs 5.7 d, P0.001), and total hospitalization duration (7.4 d vs 8.5 d, P0.001). In the intracorporeal group, on average, 19 positive lymph nodes were removed; in the extracorporeal group, on average, 14 were removed P0.001). Thus, intracorporeal anastomosis for right laparoscopic colectomy improved patient outcome by providing faster recovery of nutrition, faster recovery of intestinal function, and shorter hospitalization than extracorporeal anastomosis.Short-term outcomes favor intracorporeal anastomosis, confirming that a less traumatic surgical approach improves patient outcome.

The authors report their experience on the use of a biopsy gun for histological sampling in the field of breast lesions. The use of cytological sampling by (FNAB) fine needle aspiration biopsy has been preferred so far, because it has been thoutht to be simpler, less risky and reliable. Nevertheless, the cytological sampling shows a number of drawbacks such as the need for passes to get sufficient cellular material, frequent problems in diagnosing benign lesions and the decisive influence of the operator's skill. By using a biopsy gun for histological sampling these disadvantages are eliminated. In this case, in fact, the validity of the sample is not influenced by the operator's skill; fewer passes are necessary and their validity does not depend on the nature of the lesion. The personal series of cases involves 91 patients subjected to histological sampling for suspected lesions. Two different kinds of needles were used with one an 18 G diameter and a 23-mm extension of the sytlet, as well as a sampling window 17 mm; the other with the same diameter and extension of the stylet, as as a sampling window 8 mm. The first needle was used in all 91 patients, and the second only in 30. The results were not influenced by the employ of the different kinds of needles. A total of 268 samples were made and 110 lesions were discovered, 79 of which were malignant and 31 benign (fibroadenoma, fibrocystic change and epitheliosis). Three carcinomas were not found (3 false-negative) and one specimen was inadequate. The values of sensibility, specificity and diagnostic accuracy of the method were, respectively, 96.2%, 100% and 97.2%, with 3.8% false-negative due to three cases where the lesion was not centred for guidance mistake.

Cutaneous melanoma is one of the most studied neoplastic lesions in biology and clinical oncology. It has been well documented that this type of neoplasm presents a high metastatic rate, and is able to involve nearly every tissue. Non-cutaneous melanoma represents an unusual pattern of melanoma, and the small intestine is an uncommon anatomic localization. Herein we report an extremely rare clinical case of a young woman affected by a bleeding jejunal melanoma, whose early clinical presentation was an intestinal invagination.

In this report, we retrospectively evaluate the effect of a laparoscopic approach in the diagnosis and treatment of acute abdominal pain in patients with suspected peritonitis.We evaluated the clinical records of patients admitted to our institution between January 1995 and July 2001 with a diagnosis of acute abdomen and suspected peritonitis.Ninety four of 229 patients underwent diagnostic laparoscopy. In this series, 83 (88.3%) of the cases were successfully treated by emergent laparoscopy for an acute abdomen. Eleven (11.7%) required conversion to an open laparotomy procedure. Overall, the preoperative diagnosis was confirmed by laparoscopy in 67 (71.27%) of the cases. It was not confirmed in 27 (28.73%). Postoperative mortality was 4.25%. Morbidity was 8.5%.Data reported in the literature establish that laparoscopy offers adequate visualization of the entire abdomen and pelvic cavity in the diagnosis of an abdomen acute secondary to peritonitis. In this series, laparoscopy confirmed the diagnosis in 97.8% of the patients, and minimally invasive treatment was achieved in 88.3% of the cases. Female patients with gynecologic disease particularly benefitted from a laparoscopic approach, which permitted the correct evaluation of this condition and may have prevented unnecessary laparotomy. We believe that laparoscopy is an accurate modality for the diagnosis and treatment of patients with an acute abdomen and suspected peritonitis when the diagnosis cannot be clearly made by physical examination and noninvasive methods.

Activins are growth factors involved in the control of cell proliferation and differentiation. Human breast tissues express immunoreactive activin subunits, and activin A is able to inhibit the replication of mammary cells in vitro. The aim of the present study was to evaluate 1) whether breast cancer expresses activin betaA subunit mRNA, 2) whether serum activin A levels are altered in postmenopausal women with breast cancer, and 3) how circulating activin A levels change after tumor removal. Four groups of women (n = 158) were enrolled for the present prospective study: two groups were composed of postmenopausal women with breast cancer (n = 74) or benign lesions (n = 15); the third was a control group composed of healthy postmenopausal women (n = 62); and the fourth group included healthy fertile women (n = 7) undergoing plastic surgery with removal of non-neoplastic mammary tissue. RT-PCR showed that betaA subunit mRNA was expressed in breast carcinoma, fibroadenoma, and normal mammary tissue, and the level of expression was higher in carcinoma than in normal tissue (P < 0.05). Dimeric activin A was detectable in homogenates of breast cancer tissue at concentrations twice as high as in non-neoplastic tissue (P < 0.01). In women with breast cancer, median serum activin A levels were significantly higher than in controls (P < 0.001). The high serum activin A levels in patients with breast cancer were not correlated with the presence of lymph node metastasis, tumor grade, or tumor diameter. After tumor excision, a significant decrease of activin A in the first and second postoperative days was observed (P < 0.01; Friedman's ANOVA). Conversely, activin A levels remained unchanged after plastic surgery in healthy women. The present results suggest that activin A is expressed and secreted in postmenopausal women with breast cancer. The pathophysiological and possible clinical implications of this finding remain to be investigated.

Angiosarcoma (AS) of the breast is a rare and highly aggressive vascular cancer. It presents as a primitive or radioinduced form. The case of a 46-year-old woman who underwent quadrantectomy of the breast plus axillary lymphonode dissection and radiotherapy postoperatively (QUART) for ductal infiltrant carcinoma is reported in the following. Ten years later, the patient underwent mastectomy with immediate reconstruction, for local recurrence that was diagnosed as an AS of the breast at final pathological examination. She did not receive any adjuvant treatment due to local post-operative complications related to breast reconstruction. We criticise our thrapeutic approach and we recommend more attention about local recurrence suggesting that tru-cut needle biopsy of local recurrence of the breast after QUART, should be the correct diagnostic approach.

Although laparoscopic cholecystectomy (LC) results in less pain then open cholecystectomy, it is not a pain-free procedure. The aim of this study was to test a new method of preemptive analgesia. By simple randomization 60 patients were assigned to two groups (30 in each group). Group A, the placebo group, received 200 ml of 0.9% saline, and group B received 5 mg/kg of a local anesthetic solution (ropivacaine) in 200 ml of 0.9% saline. Local anesthetic or place solution were administer before creation of the pneumoperitoneum. Pain intensity, as rated by visual analog and verbal rating scales, and stress response data were significantly less in the group receiving ropivacaine than in the placebo group. No patients in treatment group received an additional dose of analgesic, whereas two patients in placebo group needed an additional analgesic. Our results support the clinical validity of preemptive analgesia, but the timing of intraperitoneal administration of local anesthetic is very important. Only application before creation of the pneumoperitoneum may preempt every neuronal central sensitization.

Purpose: The aim of this study was to validate a clinical scoring system for the diagnosis of acute appendicitis in childhood. Methods: The authors retrospectively applied a clinical scoring system on 197 consecutive pediatric patients operated on for acute appendicitis. They therefore looked for a correlation between the management suggested by the scoring system and pathologic diagnosis on surgical specimens. Results: Based on final pathologic specimen, surgery has been performed unnecessarily in 23% of cases. The proposed scoring system could have reduced unnecessary surgery to 2%. Only 8% of patients with acute appendicitis would have been discharged home. Sensitivity and specificity of the scoring system used in this study was 87% and 86%, respectively. Conclusion: The clinical scoring system proposed in this study could be of help in early clinical diagnosis of appendicitis to reduce the rate of unnecessary emergency surgery. J Pediatr Surg 35:1320-1322. Copyright © 2000 by W.B. Saunders Company.

To compare the transumbilical technique of laparoscopic cholecystectomy with standard laparoscopic cholecystectomy.Randomised open study.Teaching hospital, Italy.90 patients who required elective cholecystectomy under general anaesthesia.Standard laparoscopic cholecystectomy through 4 ports or transumbilical cholecystectomy through 2 ports.Amount of pain and analgesia, cost, side effects, and cosmesis.25 patients were excluded from analysis (8 in the standard group because relevant data were not recorded; and 17 in the transumbilical group in 4 of whom relevant data were not recorded, and 13 for technical reasons). 32 patients who had standard, and 25 who had transumbilical cholecystectomy had operative cholangiograms. There were no complications, no side effects, and no conversions to open cholecystectomy. Those who had transumbilical cholecystectomy had significantly lower pain scores (p0.05) and required significantly less analgesia during the first 24 hours (p0.05) than those who had standard laparoscopic cholecystectomy.Once the learning curve has been completed, transumbilical cholecystectomy is possible without some of difficulties associated with standard laparoscopic cholecystectomy.

Background: Laparoscopic splenectomy for normal-sized spleens has several advantages compared with laparotomy. Only a few cases of splenomegaly done by laparoscopy are reported in the literature. The purpose of this study is to show that laparoscopy for splenomegaly is feasible and has several advantages over the open operation. Methods: We performed retrospective chart review of 8 cases of splenomegaly managed by laparoscopy (group 1), 15 cases of open splenomegaly (group 2), and 27 cases of laparoscopic splenectomy for normal-sized spleens (group 3). Comparison has been done between groups 1 and 2 and groups 1 and 3 in terms of operative time, intraoperative estimated blood loss, need for blood transfusion, postoperative ileus, postoperative stay, and mortality and morbidity rates. Results: Patients in group 1 required longer operative time and significantly less intraoperative blood transfusion compared with group 2. The postoperative course was less complicated and shorter in group 1 than in group 2. Operative time was longer in group 1 compared with group 3. No significant differences in terms of postoperative course have been found between groups 1 and 3. Conclusions: Laparoscopy for splenomegaly is a feasible, effective, and safe technique for experienced laparoscopic surgeons. This approach seems to have several advantages over the open operation. Prospective, randomized trials would be required for a proper quantitative evaluation. (Surgery 1998;124:839-43.)

After being successfully applied to other intraabdominal organs, the laparoscopic approach has been applied to the spleen since 1991. The experience with 17 cases of laparoscopic splenectomy performed due to immune thrombocytopenia purpura (10 instances), hereditary spherocytosis (2 cases), and Hodgkin's disease where the staging was done according to Stanford (5 cases), have been reported. With the patient in anti-Trendelenburg position, and the surgeon between the patient's legs, four or five trocars are introduced into the upper abdominal quadrants and the spleen hilum is isolated. Hilar vessels are dissected and ligated with a surgical stapler. A plastic bag is introduced into the abdomen cavity and the spleen is slipped inside; it is then extracted through an umbilical incision after morcellation. Advantages of the open operation include a decrease in postoperative pain, a decrease in pulmonary sequelae, a reduced incidence of subphrenic abscesses, and cosmetic advantages. The decrease of postoperative sequelae reduces hospitalization and costs, which are higher for the operation itself (materials and staff's training).